10 Sure Paths to Unhappiness:

 

 

1.      Expect more than can ever be delivered.

 

2.      Allow your mind to erase all your accomplishments.

(It is amazing how many minds I’ve seen accomplish

 this senseless, undermining task.)

 

3.      Focus on the negative and allow doom, gloom,

 and hopelessness to overrun and take over your neuronal pathways.

 

4.      Eat a lot of rich HD ice cream, instead of training your taste buds

to relish TJ’s delicious vanilla organic yogurt. (This is just one example

 of how you might wreck your health by failing to make disciplined choices).

 

5.      Failing to recognize how your creative brain is capable of manufacturing endless numbers

 of saboteurs that flummox your brain and obstruct your personal progress.

 

6.      Indulging in hours of “bad” news (fires, earthquakes, hurricanes, corrupt politicians)

 on the TV, iPad, iPhone, etc. especially immediately before bedtime.

 

7.      Forgetting to employ the great tool of curiosity to the world and everything and

anything in it.

 

8.      Putting all your hopes and dreams on the back burner.

 

9.      Forgetting that play and hard work go hand in hand.  Whether you express and/or appreciate humor

or farce or music, the visual arts, or great theatre, forgoing enjoyment can make you miserable.

 

10.    Forgetting that you must always attempt to rebound from setbacks. 

Each of us has our own hurdles; no one is immune from them, including royalty.

 

 

On Pondering the New Normal

A May 3 New York Times article quotes Jon Grinspan pointing out that “democracy” and “pandemic” share the same root— “demos,” Greek for people. What affects us all should reflect us all.  

Although we’re all in this pandemic together that potentially affects every aspect of our lives, the impact and ramifications of the disruption vary greatly among us.

Unemployment claims have zoomed into the headlines. Clearly those who’ve lost their jobs are worse off than the employed. In April the highest rate of unemployment was recorded since jobless tracking began in 1948, the highest since the Great Depression.

Furthermore, the inequities in the workforce are fully exposed: those who serve with their hands and bodies are more likely to come in contact with the virus than the computer-technically savvy who work with fingers and brains in virtual offices.

Families with small children and two working parents experience much more stress than a grandmother who has to take care of only her pets and plants.

Many teachers experience stress from online teaching and students from online learning and the loss of peer interaction.

We’ve had to rate essential services and cut out (like diseased organs) those considered non-essential—theatre, concerts, operas and museums and restaurants that add enormously to the quality of our lives—leaving thousands of actors and musicians and restaurant workers without jobs.

One of my clients bemoaned the reality that our nation is no longer a first world-power highlighted by the government’s response to the pandemic.  What has become blatantly apparent, is that we are now a third world power in light of the president’s response and anti-scientific attitude.  

Everything changed after 9/11, as prize-winning journalist Laurie Garrett points out. She is referred to as the pandemic Cassandra, after the Greek prophetess who issued dire warnings. She sees part of our current predicament as stemming from the fact that America has never been sufficiently invested in public health. Even so, she is shocked that America “isn’t in a position to lead the global response to this crisis, in part because science and scientists have been so degraded under Trump.”

The pandemic has underscored the inadequacies of our health system, and the relationship of health insurance which depends on one’s state of employment.

Siddhartha Mukherjee, physician and author of the best seller, The Emperor of All Maladies, comments that the medical infrastructure of one of the world’s wealthiest nations fell apart, “like a slapdash house built by one of the three little pigs.”

Andrew Cuomo suspended usual record-keeping requirements, which suggests that the EHR can be an obstacle to care. It focuses on obtaining reimbursement for services rather than transmitting vital information about patients. Nor do we have a standardized digital database of patient-care records, searchable across hospital and medical-care systems.

In the May 4th New Yorker, Dr. Mukherjee credits the clinicians, who in spite of having to “wade through the muddy slop of fake news” during this crisis, have made good use of twitter and Facebook, to cobble together an informal medical bulletin board for the pandemic.

Elisabeth Rosenthal, author of An American Sickness: How Healthcare Became Big Business and How You Can Take It Back agrees with Mukherjee. Summarized in a New York Times article, her opinion is that whether it’s run by government or motivated by new incentives, the system we need is one that responds more to illness and less to profits.

The pandemic has caused us to question the value of a college education. According to journalist Masha Gessen, the pandemic has shattered “the myth of college in America.” She points out that college education does not necessarily guarantee a clear path to the future.

On a more personal level, I’ve spoken to people now working remotely from the comfort of their homes who, in spite of fears about being infected, have felt relief since liberated from oppressive bosses and work environments.

On the other hand, I’ve worked with people who are more oppressed than ever, as the virtual work load has increased and the expectation that they will devote well over 50 hours a week to meet the demands. Grateful to have their jobs, and afraid of losing them, they comply.

I’ve spoken to mothers now juggling child care and turning out the same quality and quantity of work. (Daycare centers aren’t an option now, and they dare not allow the nannies to come into their homes.)

In addition, working parents have to be more involved in their children’s education as classes move online.

Instead of experiencing relief from their commute, the teachers are embroiled in phone conversations with students and parents and feel impotent to help the 30% of the students who remain unengaged in their schoolwork.

Some clients have temporarily dropped out of treatment because their lives have become monotonous and they decide they have nothing to talk about.

Others flock to therapy because they are anxious and depressed by the radical changes and uncertainty about where they’ll be, fearing they will be left stranded high and dry on an alien beach after the dangers of the pandemic recede like ocean waves.

What Should We Expect?

The April 3 issue of Boston Review quotes Alex de Waal: “Epidemics are inflection points in evolution across different scales, from the microbial to the planetary. The post-pandemic world is a changed ecosystem.”

At best, the outcome on many fronts is nebulous. How health, environment, and politics will intersect is unpredictable and renders the outcome unknowable. If Trump and his opinions prevail, the devastation will be greater.

Most of agree, however, that the pandemic is going to affect how we think about all kinds of things, and that life after we emerge is going to be different. The territory is wide open for speculation on many fronts. What changes will persist for years after COVID19? Which will be integrated to make up the new normal? Which will vanish entirely?

Although much about the new normal is now as unsettled as a muddy puddle, some major changes are apparent on the horizon.

Quite likely, some of us will continue to Zoom and work remotely from home at least some of the time.

How will the arts fare? Will theatre, concerts, opera ever recover their pre-pandemic grandeur?

Will the subway system still be shut down to allow the trains, stations and equipment to be disinfected? How will the resurgence of infection be prevented if we’re once again, packed like sardines in the subway cars? And how will these changes impact the homeless?

Nature has had a resurgence since fewer of us clog the streets,  sidewalks and parks. I see some brilliant-colored birds frolicking and singing loudly from their perches in the trees of Central Park. Some animals have dared to show themselves during lockdowns—

a fox in the middle of a London street. Will wildlife go into lockdown after we re-emerge?

Regarding the economy, few experts are willing to predict with much certainty the current behavior of the stock market. With GDP down on a par with the Great Depression of the 1930’s, what will a recovery look like? Will it be long or short? Some businesses are closing their doors forever. Will jobs be available for the unemployed?

Warren Buffet, one of the greatest investors of all time, assures us that our future is not all downhill as some of us fear during this Covid19 time. His viewpoint is unusual for an 89 year-old, since older people tend to be more pessimistic than younger ones.

We’re in the middle of a tunnel, he says, and gratefully, he is one who sees the light at its end. He believes that we will emerge from the darkness for the better. 

We’ll evaluate our use of mass transportation including the pros and cons of travel for work and for pleasure. (The thought of even a short ride on the subway arouses my anxiety).

We’ll attend business meetings with masks or perched behind plexiglass. We’ll question whether college Is a necessary and natural step for our high school graduates as well as question whether our kids should go out of state?

If the rich get richer by benefitting from this debacle, and neglect the welfare of everyone else, Garrett suggests that we could have massive political disruption. Massive unemployment may evoke collective rage.

Now the people celebrated as heroes are “essential workers”—doctors and nurses, grocery store clerks, bus drivers, mail carriers. But will we continue to recognize their importance and reward them accordingly?

(Tragically, after 9/11 the heroes of the day, the firemen and policemen suffered years of serious physical illnesses /cancers, chronic lung and digestive disorders. Those in power denied that their illnesses were directly related to exposure to the noxious chemicals that spewed into the atmosphere and inhaled into the lungs of the heroes who pulled the victims from the burning rubble.)

A New Era for Labor

Political commentator Andrew Yang says that we are going to be faced with a national rebuilding project at a scale that has never existed in our lifetimes. The biggest battle in politics now is over who will control that project, and who it will prioritize.

Writing this blog has helped me understand why many younger people rallied behind Bernie Sanders. Some of his points have special relevance now. Perhaps he failed because he wasn’t able to combine a style with his content that would appeal to the majority of Americans.

The time is critical for the essential workers and the unemployed to band with the young people, among whom are the Sanders’ supporters, to usurp some political power to bring about a more equitable political system: to guarantee accessible health care, childcare, and college or relevant job preparation, and environmental protection  (for the ecology, our water, our climate, our oceans and our animals). Andrew Cuomo has proved himself as savvy, sane and scientific, a savior in this time of turmoil. Hopefully, he’ll pursue and impose justice in the face of rampant political corruption and overt racism.

Conclusion: With many of our assumptions about the way our country works collapsing around us, we are going to be faced with a national rebuilding project that has never existed in our lifetimes, as Yang has said. The biggest battle in politics now is over who will control that project and whom will it prioritize.

Dear Reader, Please, feel free to send your comments. Jsimon145@gmail.com

Telemedicine (and me)

Telemedicine and telehealth have been with us for decades, but with the onset of the pandemic, it has become a vital tool, catapulting to the forefront of medicine. With the continued requirement for social distance, its use and acceptability are expanding at unprecedented rate. The availability of electronic equipment and reliable broadband, along with our ability to use them, are also contributing to increase. Long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions are now possible.

Before this recent acceleration, telehealth/telemedicine had provided treatment to offset costs in rural settings, in situations where sufficient staff wasn’t available, or where transportation or immobility made in person treatment untenable. Now, NYU Langone books an average of 4000 telemedicine appointments a day.

Some organizations and countries distinguish between telehealth and telemedicine; Telemedicine specifically focuses on diagnosis and treatment; whereas telehealth includes communication between clinicians, and between facilities, home monitoring of patients through the transmission of health data as well as non-clinical applications like administration and provider education.

Practically every specialty can now partake in remote medicine, including surgery with the help of robotic assistants. It has proved useful for post-operative monitoring and care as well as telerehabilitation. (Of course, telemedicine’s limitations become obvious when a hands-on examination is necessary, like a yearly physical or a gynecological exam.)

Telenursing is also growing in many countries to treat the increasing number of aging and chronically ill population, to help with the nursing shortage, save time and costs and keep patients out of the hospital. As a result, nurses have reported greater job satisfaction. 

Telehealth facilitates medical disciplines to merge and improve the level of care. The everyday medical and psychological visits as well as those that extent beyond the quotidian. Trauma specialists can interact with personnel on the scene of a mass casualty or disaster via the internet to provide clinical assessments and determine the severity of injuries, and whether injuries warrant evacuation. Remote trauma specialists provide the same quality of clinical assessment and care as a clinician on-site.

Telemedicine is being used in some ICU’s to reduce the spread of infection and is especially useful in communicating among caretakers to relay information for patients’ care between day and night shifts.

The team of attending, residents, fellows, nurses, nurse practitioners and pharmacists are able to watch live video from a patient’s bedside, see the patient’s vital signs on the monitor, view settings on a ventilator, and assess a patient’s wounds. Video-conferencing allow the remote practitioners two-way communication with clinicians at the bedside.

Telepsychiatry

Perhaps nowhere is telemedicine more effective than in psychiatry. Telepsychiatry has been a valuable tool for several years to deliver care to underserved areas. A few years ago, I attended an APA meeting where a young psychiatrist presented. She had designed markers to support the efficacy of telepsychiatry in treating a rural population. Her results were positive and her enthusiasm was impressive and contagious.

Telepsychiatry has been found to be as effective as face-to-face treatment. Since the pandemic, it has become the major method of treatment for diagnosis and assessment, medication therapy management and in-depth psycho-dynamic psychotherapy. And may be even better than in-person treatment for children, veterans and individuals with agoraphobia.

The change in living situations, necessitated by the pandemic has raised many profound issues and increased anxiety and depression for several of my patients who now require intense treatment. 

Telepsychiatry has another advantage of adding an extra dimension of making a home visit possible via Skype. One session focused on helping a woman-homemaker whose symptoms revolve around disorganization and clutter.

During an interview with a new patient (who was tense and hesitant to relate her history) the ice was broken when her cat wandered across the screen and evoked our mutual amusement.

Another patient, who had selected me as her psychiatrist because of my photo with my dog, was able to see him in my home office. 

The advantages of telemedicine are numerous and include:

1.Greater access to treatment improves patients’ health

2.Decreases time spent traveling

3.Cuts down on office costs 

4.Offers greater access to expert care 

      5.Helps to cut down on hospital time

6.Makes fewer demands on the healthcare system

With the possibility of self-monitoring, patients have a greater sense of control and may be more willing to stay on their treatment plans as they are more invested and included in the process. 

Remote monitoring or self-monitoring has been especially useful for managing chronic diseases or specific conditions like heart disease, diabetes, and asthma. And have been found to provide health outcomes comparable to traditional in-person visits.

But there are still barriers to wide-scale adoption, including:

The regulatory challenge of obtaining licensure across multiple states, malpractice protection and privileges at multiple facilities. (Although this consideration is also experiencing a great deal of flux.)

Resistance by government and insurance carriers to reimburse for the practice of telemedicine. 

The reluctance by physicians to change the way they practice.

FUTURE 

With continued use and research regarding the efficacy of the vast possibilities in each medical specialty, the government and more insurers will cover the vast range of therapies that avail us all now through the ever-increasing availability of technology. 

Although its future in post-pandemic days is uncertain, many experts agree that this valuable tool will be integrated and used more widely than before the onset of social distancing.

N.B. I’ve excerpted some details from a scholarly article. My brief blog is by no means comprehensive in any way. I hope the tidbits of personal experience add to the mix. I’m most fortunate and grateful to be able to continue treating my patients via telepsychiatry without a glitch thanks to Fieve Psychiatry (212-249-1600) and our manager Paula Puia. With her technical skills and know-how, she rapidly set up the system that offers confidentiality via Skype. She and the staff process the paperwork to secure reimbursement from a variety of insurance companies. 

MASKS: PREJUDICES AND POSSIBILITIES

Few of us like to wear masks. They stigmatize. We can feel contaminated, tainted, like Hester Prynne in Nathaniel Hawthorn’s classic, The Scarlet Letter, the story of the woman condemned to display an “A” on her breast to shame her for the sin of adultery.

The assumption of wearing a mask is that we are sick and should be shunned. Some bosses have forbidden their workers to wear masks, fearing that people will assume they are sick and frighten the customers. In the past, we’ve associated mask-wearers with hiding, used to disguise the wearer. A bank robber’s mask conceals his identity. In the musical, “The Phantom of the Opera,” the lead character wears a mask to hide his deformed face.

Masks have been with us for a very long time, with the oldest dating to around 7000 BC.

They were first used for rituals and ceremonies in many places of the world, usually representing supernatural beings, ancestors, and imagined figures. In China, they are thought to originate in ancient religious ceremonies. Native American masks were used for spiritual practices, entertainment and medicinal functions. Halloween masks originated in the Celtic culture, used as disguises to confuse the ghosts that emerged in the fall. Masks have also been used in hunting, feasts, wars, performances, theatres, fashion, ornamentation, sports, movies as well as for medical, protective or occupational purposes. In Italy during the 16^th century, elaborate dances or masquerade balls, invited members of the upper classes to flaunt different colors to symbolize traits like elegance, dignity, sophistication, mystery and seductiveness. 

My associations to mask-wearing go back decades to a long-forgotten memory of my mother, who raised her babies in the 1950’s. When she was sick with an upper respiratory tract infection, she covered her nose and mouth with a soft, white, washable cotton mask to protect the baby when she held him to her breast to nurse.

Also, while a medical student, I attended operations with surgeons who never seemed troubled by their masks that protected the patient as well as themselves from the exchange of germs and bodily fluids. They managed to endure the mask for long hours, under strong lights on their feet performing delicate manipulations of tissues. 

STIGMA

A helpful April 7 article in the Wall Street Journal reframes the symbol of stigma to caring about another person’s safety.  Wearing a mask is not a signal that we are contaminated but a statement that says, “I care about you. I want to protect you.”

We look to a president as children look to parents to teach proper behavior that aids our survival in the world. Some parents, like some presidents, steer us in sanguine directions. But President Trump shuns wearing a mask. I venture to guess that his stance stems from machismo; to him wearing a mask blares VULNERABILITY. But his behavior is self-centered, ignoring the fact that a mask also protects and shows caring about the health and safety of others. 

If a mask isn’t available, we compromise with a thick, nonporous fabric lined with a layer or two of paper towels that effectively filters the air. Directions can be readily found on the internet. 

THE DOWNSIDE

The downside is that we have to endure the discomforts and inconveniences of these face coverings. Breathing into them heats up the air and causes us to perspire and our noses to run. Even surgeons in the OR had to request an assistant to wipe the perspiration from their brows occasionally.

An N95 allows air to sneak around it if not properly fitted. We have to be wary of continuing to adjust the mask. We have to remember not to touch our faces that may itch from the mask.

Filtering air slows down air flow and breathing can be difficult. Wearing a mask can give a false sense of security, causing us to assume we’re safe and don’t need to wash our hands. 

A dirty mask is a source of contamination. We have to remember to wash hands before putting on and after taking off the mask.

Under the confines of the mask, some of us are likely to produce more bodily fluids—We perspire and our noses tend to run under the heat of the mask and the repeated exhalations that warm our faces.  So we have to be ready with a tissue to wipe away the bodily fluids produced by wearing the gear that it protects us and others while also inconveniencing us.

THE POSITIVE SIDE

On the positive side, the mask is a psychological signal that we are in a pandemic and a 

 visual reminder to wash our hands and maintain social distance. It also gives us a sense of control when we have so little control in our situation

It behooves us to stay as healthy as long as possible, at least until we have more information, and drugs proven to treat and vaccines proven to prevent. It is reassuring to remember that many people perished in the early days of the HIV epidemic until medicines were discovered to keep them healthy for a lifetime.

We cannot maintain our social distance forever. Inevitably, we have to return to our workplaces; the stores and restaurants must open their doors. We want the arts to return; we want to attend the theatre, concerts, the opera.

A fact is that coronavirus, like the flu is here with us to stay. Able to mutate and afflict unpredictably, the rate of affliction/infection will ebb and flow, increasing and decreasing according to the weather and innumerable other factors, as yet to be defined/determined.

The French existentialist, writer Albert Camus in his 1947 masterpiece “The Plague” spells out the human predicament: our vulnerability, that we can be exterminated at any time by a virus, accident, or another human being. He points out that the threats are ever-present and that no one is immune. For our mental sanity, we don’t often dwell on this reality.

A neat solution to our present situation of having to live with the coronavirus and future pervasive infections is to don our masks with pride, to see them not as a sign of stigma, but as a statement of caring for self and others. 

We could even begin to view them as an extension of our wardrobe, like earrings, necklaces, neckties, hats or body piercings. They can ornament and decorate us. We can be creative and inventive regarding their style, color, material. 

Companies can invest in designers who could style them for the seasons— darker colors in winter, lighter shades for summer and with the right fit like bras, to accommodate different sizes and shapes of faces, instead of breasts. They could fashion various kinds of nozzles, airways to filter out viruses and impurities in the air.

Designers and scientists can work to discover new fabrics, washable and fast-drying, woven to combine breathability with the most effective filter.

Instead of an onerous symbol, a mask will be a fashion statement. I envision one person saying to another, “What a beautiful mask! Where did you get it? I’d like to have one like it. Do they have any more?”

In summary: The mask has a long and varied history and for better or worse, will be an essential part of our future. Let’s consider the possibility of the mask as a fashion statement as well as a symbol of caring for others. 

Dear Reader, I welcome your comments: jsimon145@gmail.com

Some Upside to Our New Reality

To help me adjust to life in the midst of the pandemic, I try to focus on the positive as I speak to others and stay informed of the latest details in the news about the virus.  

First of all, we are all in this together. The novel coronavirus strikes indiscriminately. Not even  the rich and famous are immune; this change can be heartening when inequalities and injustices in our country had soared along with the stock market.

All aspects of life in our world have been altered, from the environment to our personal hygiene. Everything has been impacted: family life, business, health care, technology, politics and the arts. 

In terms of the environment, a benefit is that the pollution has diminished as a result of less travel and traffic and the closing of factories.

Technology provides us with tools to teach students and conduct business remotely and opens up the need for further development of cloud-based technology.

Telemedicine is expanding as its benefits are more widely recognized: an ability to reach more people, more quickly to diagnose and treat.

Regarding our work life, I hear stories every day of how people are doing better work at home without the distractions of colleagues and bosses in the workplace. (But it has added a stressor to parents’ lives, many of whom have to work from home while they homeschool their children.) 

Some bosses even prefer that their teams work remotely, saying that this method puts workers on a more equal footing and enhances communication. 

Meetings and conference calls are better appreciated because they meet the need for outside contact and connection.

Staying in one place adds time to our schedule, allowing some of us the chance to pursue our hobbies and creative projects. Without the possibility of dining out at restaurants, some relish the chance to cook healthier, homemade meals. A surge in sales of seeds and potting soil shows that people are gardening. Ms. W, for instance, is planting vegetables on her terrace and looks forward to eating what she grows. Others have more time to practice their musical instruments. Mr. S. ordered a new piano for his apartment. Some of us are studying a new language. Others find that working on a large jigsaw puzzle can be a kind of meditation, something they can do with or without help from others.

Some now have the chance to explore relationships with their families, especially beneficial for younger people who have lived apart and return to their family home for space, comfort, camaraderie. 

Husbands have become more better teammates, pitching in to help their working wives in the home with their children.

Teachers are receiving appreciation by parents who have the chance to view their children’s school work online.

Pets are delighted to have us around and with their soothing ways, provide good company.

We have time to reach out to old friends and check in with older relatives who live far away.

Workers who continue to serve us are receiving more appreciation and delivery people are receiving bigger tips. 

Artistic communities, theatre, music, libraries and our gyms have reached out to connect, offer support to keep us entertained and healthy.

Even big business is finding ways to help: 

1.     Apparel companies are making masks and other protective garments. 

2.     Big companies are producing ventilators and N95 respirators and a car-parts company is producing hygienic masks.

3.     Tech companies are donating computing power to crunch data and search for a cure.

4.     Distilleries and breweries are making hand sanitizer.

5.     Leaders are learning about empathy, treating their employees in a human-centric way—

compensating for lost hours, covering sick pay, assisting with child care and avoiding layoffs. 

    

6.     Luxury hotels and cruise ships are becoming makeshift quarantine shelters.

At normal times, we rarely stop to think how we’re all part of the fabric of the human family. Now, more than ever, we have become aware that international coordination is vital to cope with the current apocalypse. 

Dear Reader, I welcome your comments about how you have found positive ways to cope with our new reality.

Jsimon145@gmail.com